KINGDOM OF CAMBODIA NATION – RELIGION - KING

Ministry of Health

DRAFT

ANNUAL HEALTH FINANCING REPORT

2012

BUREAU OF HEALTH ECONOMICS AND FINANCING DEPARTMENT OF PLANNING AND HEALTH INFORMATION

MARCH 2013

ACKNOWLEDGEMENTS Special thanks go to Mr. RosChhunEang, Chief of the Bureau of Health Economics and Financing, Department of Planning and Health Information, Ministry of Health, for his tireless effort in collecting data and writing this report. And sincere thanks also go to staff of the Bureau of Health Economics and Financing, the Department of Planning and Health Information for their contribution to this publication. Appreciations go to Dr. Lo Veasnakiry, Director, Department of Planning & Health Information, for his technical input and editing work.

Sincere appreciations also go to concerned Departments, especially Department of Budget and Financing, MoH, Provincial Heath Departments, Operational Districts, and National Hospitals, Referral Hospital and Health Centers, as well as demand-side financing operators, for their kind cooperation in providing the information.

The Department of Planning & Health Information would like to express high appreciations to World Health Organization for providing support to the development of the report. Contact Address

Bureau of Health Economics and Financing Department of Planning & Health Information Ministry of Health #151-153, Kampuchea Krom Blvd, Phnom Penh Email: chhuneang@online.com.kh

TABLE OF CONTENTS

FOREWARD ACKNOWLEDGMENTS

EXECUTIVE SUMMARY .......................................................................................................................... 1

1. BACKGROUND ..................................................................................................................................... 4

1.1 INTRODUCTION ................................................................................................................... 4 1.2 HEALTH SYSTEM DEVELOPMENT .................................................................................. 4 1.3 MINISTRY OF HEALTH STRATEGIC PLAN .................................................................... 6 1.4 HEALTH INFRASTRUCTURE ............................................................................................. 7 1.5 HUMAN RESOURCES .......................................................................................................... 8 1.6 HEALTH SYSTEM FINANCING ......................................................................................... 8

2. OVERVIEW OF HEALTH CARE FINANCING IN CAMBODIA ................................................. 10

3. HEALTH FINANCING FLOW IN HEALTH SECTOR ................................................................. 11

4. HEALTH SPENDING ANALYSIS .................................................................................................. 12

4.1 TOTAL HEALTH EXPENDITURE (THE) ......................................................................... 12 4.1.1Government Budget Allocation and Expenditure for Health ................................................. 13 4.1.2 Health Partner Expenditure .................................................................................................... 14 4.1.3Household Health Expenditure ............................................................................................... 15

5. ANALYSIS OF THE HEALTH FINANCING SCHEMES .............................................................. 16

5.1 SUPPLY SIDE FINANCING SCHEMES ............................................................................ 16 5.1.1 User Charges and Exemption for the Poor ............................................................................ 16 5.1.2 Special Operating Agency and Service Delivery Grant ........................................................ 17 5.1.3 Government Subsidy for the Poor ......................................................................................... 18

5.2 DEMAND SIDE FINANCING SCHEMES ......................................................................... 21 5.2.1 Health Equity Funds .............................................................................................................. 22 5.2.2 Voucher Scheme for Reproductive Health Services .............................................................. 26 5.2.3 Health Insurance .................................................................................................................... 29 5.2.4 SOCIAL HEALTH INSURANCE......................................................................................... 30 5.2.5 Voluntary Health Insurance Schemes .................................................................................... 31

6. PROGRESS TOWARDS HEALTH FINANCING STRATEGIES INCLUDED IN THE HSP2 .... 36

7. GLOSSARY ...................................................................................................................................... 38

8. REFERENCES .................................................................................................................................. 39

EXECUTIVE SUMMARY

How much was spent on health? Financed by three main sources – development partners, Government, and household out-of-pocket spending, Total Health Expenditure (THE) has substantially increased over the last five years, from USD 564 Million in 2008 to USD 763 Million in 2012, representing more than 5% of the GDP. In 2012, THE was approximately USD 52 per capita, 24% of which comes from Government spending, 15% from development partners, and the remaining 61% from out-of-pocket spending. Where did the money go? Health is highly recognized by the Government of Cambodia as a priority sector for investment. National budget allocation for health has consistently increased over the last ten years, reached USD 197 Million in 2012. The current national budget allocation is 70%-30% central and provincial level allocation, respectively. Who provided the funds? National Health Expenditure as a percentage of the approved budget is over 95% in 2012. Total Government expenditure for health in 2012 was estimated at USD 187 Million, approximately USD 13 per capita, representing approximately 24% of THE. As a percentage of total Government recurrent spending, government health expenditure was highest in 2010 at 11.94%, with a reduction in 2010 at 10.91%, followed by an increase to 11.54% in 2012. Development partner support to the health sector in 2012 was 141 Million USD, approximately USD 10 per capita. External spending for health was estimated at 15% of THE in 2012, at around 116 Million USD. Household health expenditure, via OOP, contributes the greatest part of the THE. Since 2008, OOP has increased from USD 25 per capita in 2008 to USD 32 per capita in 2012 or approximately USD 459 billion, accounting for 61% of THE. Equitable funding Since the limited of risk pooling mechanism, irrespective of private or public health providers, fee-for-services dominate. This form of payment is highly regressive since the poor spend a higher share of their income than the non-poor to obtain the same treatment. Furthermore, since user fees are paid on an individual basis whereby each patient or caretaker spends for his/her treatment, risk sharing is not possible Development in health financing schemes with supply and demand-side interventions The Cambodian health system is financed by both supply and demand side financing interventions. Supply-side schemes aim to increase access to services by the poor while improving service quality. These schemes include user charges and exemption for the poor, special operating agency and service delivery grant, midwifery incentive and government subsidy for the poor. Demand-side schemes aim to remove financial barriers to access and increase utilization of health services. These schemes include Health Equity Funds (HEF), Voucher schemes, and Community Based Health Insurance (CBHI).

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Health Financing of Schemes Subsidy is financed by the national budget through MOH budget. Total expenditure for 2012 was USD 469,331, 50% of which was spent at national hospitals, while the remaining 49% at referral hospitals and 1% at health centers. In 2012, the total HEF expenditure was USD 9,457,954, 85% of which was spent for direct benefit to the poor patients and other 15% for management and operation of the schemes. In 2012, the total expenditure funds for HEF reimbursed by HSSP2 was around USD 9.19 million, 84% of which was for direct benefit costs (medical and non-medical costs for the patient) and 16% for operating costs. In 2012, HEFs paid on average USD 8.40 per case to HC and USD 29.32 per case to referral hospitals. HEF reimburses on average USD 1.01 per OPD case at HC and USD 6.44 per OPD case at RH, with USD 29.24 per IPD case at referral hospital. Of note, 89% of the total HEF direct cost (USD 7,967.377) paid referral hospital services used by HEFs beneficiaries and only 11% for health center services. Voucher project for reproductive health services is financed by KFW as a grant. Total expenditure, including direct cost and indirect cost is USD 626,360, 63% of which was spent for direct cost and 37% for indirect cost (operation). The income of CBHI scheme is estimated around USD 656,806 in 2012. On average only 28 % came from premiums paid by members while majority of income (72%) came from other sources, mainly donor funding. The total expenditure in 2012 was USD 622,715 with 46% spent for medical fee, 34% for administrative cost, and 10% for transportation cost of patients, 4% for outreach and marketing and 2% for other cost. It is observed that only a few CBHI schemes can operate by relying solely on premiums; other schemes, especially those with high membership, must use other subsidies to support their function. Strategic Framer work for Health Financing 2008-2012 Strategic Framework for Health Financing 2008-2015 introduced in 2008 is one of the major components of the Health Strategic Plan 2008-2015. The framework included the following strategies:

1. “Increase government budget and improve efficiency of government resource allocation for health.” Budget for health has increased

2. “Align donor funding with MOH strategies, plans, and priorities and strengthen coordination of donor funding for health”. Donor partners plan to continue and increase resource commitment.

3. “Develop social health protection mechanisms to reduce financial barriers”. HEF scale-up continues, with 76% of the targeted poor already covered. Also, wide implementation of poverty targeting tools and social health insurance for workers supports removal of financial barriers at the point of care.

4. “Move towards managing resources near service delivery level”. Government aims to devote greater resources to MCH incentives, as well as support an active role of PHDs in resource utilization design and implementation.

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5. “Use evidence & information to inform health financing policy-making”. Since late 2011, this has been supported by systematic reporting, studies and researches led by Department of Planning and Health Information as well as other Departments.

What were the changes in health policy? The current status of the health care system in Cambodia is one of a publicly funded district-based health sector and a fast growing private sector primarily funded by out of pocket. Each operational health district has multiple health centers providing the first line of health services (Minimum Package of Activities) with a catchment of 10,000 and a referral hospital providing second or third line health services (Complementary Package of Activities) to a population of 100,000 – 200,000. This system faces a number of constraints to offering quality health services, ranging from insufficient funding and inadequate management capacity to low staff remuneration and limited medical clinical skills. The Health Coverage Plan (HCP) of 1995-1996 provided guidelines for strengthening District Health Systems. During this time as well, the Ministry of Health issued a circular, No 85, supporting the development and implementation of the Health Coverage Plan for Districts and Communes. The Plan immediately resulted in the development of health service by defining criteria for the location of health facilities and their ‘Catchment Area and Population’, as well as the allocation of financial and human resources. However MoH needs to go along with Decentralize & De-concentration program, and other reform such as public administrative and financial management reforms of the government. Moving Forward Significant increases in THE over the last five years, as well as support from financial sources including the Government, development partners, and from out-of-pocket spending has brought up the THE to more than 5% of GDP, relatively higher than other neighboring countries, however the financing system is still in fragmented with limited pooling function. Universal Health Coverage (UHC) is universal goal endorsed by the United Nation and ASEAN counties with strong commitment from member states. Cambodia has strong commitment to UHC. The new draft of health financing policy’ vision is to enable active participation of all residents of Cambodians in society through a health system that provides universal access to an essential package of quality health interventions in a regulated health market based on fairness of contributions and equity in access, thereby providing protection against impoverishment due to ill health. The underlying principles of the health financing system are:

• Universality: equitable access to essential curative, preventive, promotive and rehabilitative health care services, irrespectively of socioeconomic status

• Poor and vulnerable (first): the health financing system developments will ensure inclusion of the poor and vulnerable as a means of socioeconomic development

• Financial protection: access will be guaranteed irrespectively of available money • Health care services: shall be effective, provided in an efficient way and acceptable • Good governance: the health financing system follows the rule of law and is responsive

to present and future needs of society • Accountability and client oriented: health providers are accountable for the quality of

their services that must be patient-centred

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1. BACKGROUND

1.1 INTRODUCTION In the context of health sector reform introduced in 1995, the Health Financing Charter 1996 allows public health facilities to implementuser charges together with exemption policy for the poor, and pilotother health financing initiatives. Since then Cambodia has become agrounds for pilot experimentation of both supply and demand side health financing initiatives. Demand side financing to leverage quality of health service through purchasing power of the third party payersincludes schemes such as health equity funding (HEF), community based health insurance (CBHI)and voucher schemes. HEF in particular has become one of the Ministry of Health (MoH)’s health financing mechanisms to improve access to health service for the poor and vulnerable people. Supply side financing to improve health service delivery includes schemes such asuser fee with exemption mechanism for the poor, subsidy scheme,autonomous hospitals and Special Operating Agency (SOA). Despite the multiple demand and supply-side initiatives, financing through budget and subsidization through the general government resources remains the main funding instrument of services. This report provides updated information about the status and financial information of health system financing as well various health financing schemes, which are currently implemented in Cambodia.

1.2 HEALTH SYSTEM DEVELOPMENT The country health care system is composed of a district-based public health sector mainly funded by government and a fast growing private sector mainly funded by out of pocket. For the public health sector, each operational health district has a number of health centers providing first line health services (Minimum Package of Activities) with a catchment’s population of 10,000 and a referral hospital providing second or third line health services (Complementary Package of Activities) to a population of 100,000-200,000. In general, those hospitalsare fairly equipped and staffed. However, they are facing a number of constraints to offering quality health services, ranging from insufficient funding and inadequate management capacity to low staff remuneration and limited medical clinical skills to some extent. Table 1 provides a description of Health Sector Reform efforts in Cambodia and its implementation from 1995 to the present.

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Table 1: Overview of Health Sector Reform

1995-1996 Health Coverage Plan (HCP) Development

• Guidelines for Strengthening District Health System 1996-2000- introduced in August 1995

• Minister of Health issued and widely disseminated “Circular” No 85 dated 24 August 95: Development & Implementation of “Health Coverage Plan” for District & Communes.

• HCP development nationwide- central extensive support • Minister of Health issued “Prakas” on HCP in Cambodia, dated 24

July 1996 HCP of each municipality/province signed by Governor &PHD Director

• Ensure that population health needs are met in an equitable way through coverage of the whole population.

• Develop health services by defining Criteria for the location of health facilities and their “Catchment Area and Population” Allocate financial and human resources.

Implementation of the Reform Institutional development

• Minister’s “Prakas” No 308, 1997: Organization of PHD & OD Guidelines for Developing OD, 1998

• Semi-autonomous institutions sub decree • Special Operating Agency Sub-decree

Capacity building HR management

• MPA Modules, CPA training, HSMT, HMT • JD for central MoH and OD; Functional analysis linked PMG,

MBPI= currently Priority Operating Cost (POC) Financing • National Health financing Framework1996, this provided legal

framework to implement alternative Health Financing. • Strategic Framework for Health financing 2008-2015 • Draft health financing policy

Supply Side Financing

• Annual planning process 98 for PHD, revised 2003for ALL, • AoP& 3YRP for central & Province, Annual HS-AoP, 3YRP, PIP • Budget Allocation formula 96, reviewed 2005? • Introduced Accelerate District development (ADD) 96, Priority

Accelerated Program, Program based Budget PBB 2007 • Special Operating Agency and service delivery grant Manual • Inter-MinisterialPrakas (MoH) and (MEF) 2007 • Guideline for the implementation of Health Financing2010

Demand Side Financing

• Monitoring and Evaluation Framework for health equity fund 2003 • Guideline for Implementation of Community Based Health

Insurance • Social Health Insurance Master plan 2005

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• Guideline for Health Equity Fund Implementation 2008 • Financial Manual for Health Equity Fund 2008 • Social Health Protection Master Plan 2009 ( Draft)

M & E, supervision • Health information system web base • Integrated supervision checklist • Indicator Framework for Monitoring and evaluation GIS • Health financing quarterly report • Health equity fund quarterly report • Community based health insurance quarterly report • Joint annual review event

Logistics & supply system

• “ Quota” system for drug allocation, management, distribution system (centralization)

Infrastructures • Standard design for Health Center (HC) and Referral Hospital (RH) Policy & strategic planning, legislating

• Health Sector Strategic Plan 2003-2007, and 2008-2015

Coordination • Adopted SWIM, TWGH, PRO-TWG

1.3 MINISTRY OF HEALTH STRATEGIC PLAN The Ministry of Health has successfully implemented the First Health Strategic Plan (HSP1 2003-2007) and is currently implementing the Second Health Strategic Plan (HSP2 2008-2015). HSP2 clearly states its vision, mission, and working principles as follows: Vision:A long-term broader vision of the Ministry of Health is “to enhance sustainable development of the health sector for better health and well-being of all Cambodians, especially of the poor, women and children, thereby contributing to poverty alleviation and socio-economic development.” Mission:To provide stewardship for the entire health sector and to ensure a supportive environment for increased demand and equitable access to quality health services in order that all people of Cambodia are able to achieve the highest level of health and well-being. Values:A value-based commitment of the Ministry of Health is Equity and the Right to Health for all Cambodians. Working Principles:Increased efficiency, accountability, quality and equity will be achieved only through application of morality, strong beliefs and commitment to common goals by all who are working in health care. Therefore the day-to-day activities of health managers and staff in all areas throughout the organizations at all levels should be guided by five principles.

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1. Social health protection,

especially for the poor and vulnerable groups

To promote pro-poor approaches, focusing on targeting resources to the poor, groups with special needs, and to areas in greatest need, especially rural and remote areas, and urban poor.

2. Client focused approach to health service delivery

To offer services with emphasis on affordability and acceptability of services, client rights, community participation and partnership with the private sector.

3. Integrated approach to high quality health service delivery and public health interventions

To provide comprehensive health care services including preventive, curative and promotive in accordance with nationally accepted principles, standards and clinical guidelines, such as MPA and CPA, and in partnership with the private sector.

4. Human resources management as the cornerstone for the health system.

To be operational and productive driven by competency, ethical behavior, team work, motivation, good working environment and learning processes.

5. Good governance and accountability

To provide stewardship for both the public and private sectors, focusing on a sector wide approach, effective planning, monitoring of performance, and coordination.

1.4 HEALTH INFRASTRUCTURE There has been a remarkable development of health infrastructure over the last 5 years. Figure 1 indicates the number of public health facility- referral hospital, health center and health post- from 2008 to 2012. As of December 2012, the public health facility is comprised of 8 national hospitals (NH), 82 referral hospitals (RH), 1,024 healthcenters (HC) and 121 health posts(HP). Expansion of health infrastructure has increased geographical access to health services by the population, but not automatically increased the utilization of health service unless financial barriers are removed or reduced at the point of service use. It is noted that investment in infrastructure will have significant implication on human and financial resource to support health service delivery.

Source: Bureau of HIS, DPHI, MoH 2012

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1.5 HUMAN RESOURCES Although human resource remains a pressing issue, there has been a positive trend in recruitment and deployment of public health personnel. As of December 2012, the total number of health personnel employed in the public health sector is 19,721. Table 2 shows the number of health personnel by category and by year from 2008-2012. The distribution of health personnel by level is 77% at provincial (including district level) and 22% the Central levelincluding Phnom Penh (10% at national hospital, 6% at national centres and other central health institution, 4% at Phnom Penh Municipality and 3 % at the Central MoH).

Source: Department of Personnel, MoH 2012

1.6 HEALTH SYSTEM FINANCING Strategic Framework for Health Financing 2008-2015introduced in 2008 is one of the major components of the Health Strategic Plan 2008-2015. The framework includedthe followingpolicy statement and strategies:

• Policy Statement 1. Allocate existing resources and ensure their efficient use at service delivery level 2. Advocate for stronger government taxation and revenue collection 3. Mobilize and allocate resources to under-funded health priorities 4. Implement de-concentration and decentralization, using sound planning and

financialmanagement tools, provincial block grants and internal contracting 5. Move aggregate resources from inefficient private health care provision to an

efficient health care system through enhanced quality and improved access to public health services.

Description 2008 2009 2010 2011 2012Total number of health workforce 18,096 18,113 18,302 18,814 19,721

Medical Doctor, specialist docutor, professor 2,173 2,162 2,139 2,180 2,178

Medical Assistant 1,220 1,147 1,087 1,052 1,018

Dentist 172 177 189 212 214

Pharmacist 427 435 464 474 486

Secondary Nurses 5,084 5,098 5,155 5,366 2,432

Primary Nurses 3,407 3,404 3,359 3,381 5,662

Secondary Midwife 1,806 1,825 1,863 1,994 2,164

Primary Widwife 1,439 1,616 1,815 1,997 3,366

Secondary laborator 428 420 424 442 454

Others include dotor of pharmacy, assistant and primary, other skil ls. 1,940 1,829 1,807 1,716 1,747

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6. Implement social health protection measures and advocate for development of a social health insurance system.

7. Use health financing mechanisms as a leverage for quality of health services 8. Support harmonization and alignment for results 9. Empower communities to participate in local policies and decisions that affect their

financial access to health services.

• Strategies 1. Increase government budget and improve efficiency of government resource

allocation for health. 2. Align donor funding with MOH strategies, plans and priorities and strengthen

coordination of donor funding for health 3. Remove financial barriers at the point of care and develop social health protection

mechanisms 4. Efficient use of all health resources at service delivery level 5. Improve production and use of evidence and information in health financing policy

development.

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2. OVERVIEW OF HEALTH CARE FINANCING IN CAMBODIA The table below presents an overview of the current health financing mechanisms in Cambodia. The individual mechanisms are described in greater detail in later sections

Financing Mechanism

Implementer/

Operator

Target population

Benefit/services Provider Payment Method

Coverage

Tax funding via Government budget

MEF/MOH/PHD/OD/RH/HC

All population sectors Recurrent budget, drug and material supplies

Line item budget and in kind including equipment and drug

Nationwide public health facilities

User feeexemptions MOH/health facilities

Poor patients MPA and CPA123 User fee exception

Nationwide

Global health initiatives and national programs

National programs

Patients with TB, malaria, AIDS, and children for vaccination

TB, Malaria, AID patients and children age under 1 year

Free of charge Nationwide

Health Equity Fund (HEF)

NGOsfor HEFs

The eligible poor (those under the national poverty line)

MPA and CPA services , food, transport, funeral expenses

Official standardised Case base payment

In 46 Referral hospitals and 290 health centres, covering approx. 78% of the target group

Government Subsidy schemes (SUBO)

MOH/PHD/OD

The eligible poor (those under the national poverty line)

MPA and CPA services Official Flat rate

In 6 National Hospital and 11 referral hospitals and 57 health centres

Community base health insurance (CBHI)

NGOs Mainly informal sector, people living above poverty line

MPA and CPA services , food, transport, funeral expenses

Capitation, case base, fee for services.

19 schemes with 17 RHs and 1 NH and 231 HCs, covering 166,664 persons. . <1% of the population

Vouchers for reproductive health

NGOs Poor women Reproductive health services Fee for services

In 9 ODs with 5 Hospitals and 118 HCs and 4 private clinics. Covering 107,763 women.

Occupational Risk MOLVT/NSSF

Formal private sector workers

Medical treatment, temporary/ permanent disable, funeral expenses and survivor benefit

Fee for service Covered 3,921 enterprises with 745,275 workers

Maternity Benefits MOLVT/NSSF MOSVY/NSSFC

Pregnant women formal sector workers and civil servants (spouses)

3 month maternity leave with 50% salary for workers. For civil servants, 3 month maternity leave with full salary and cash incentive of USD150 per newborn

Base on salary Nationwide

Midwifery incentive MoH, PHD, OD and HF

Midwife attending delivery

$15 per live birth at HC $10 per live birth at RH

Case reimbursement

All public health facilities

Social health insurance (SHI)

NSSF NSSFC

Formal sector workers and civil servants

Still to be defined Study about case base payment

A formal private sector worker is transferred from HIP piloted to be managed by NSSF in Sept 2013.

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Special Operating Agency (SOA) facilities

MOH/Donors/ HSSP

All population in the coverage area

Decentralize together with Performance-Based Incentives for Providers

Line item and Special Delivery Grant (SDG)

In 30 Operational Health Districts

3. HEALTH FINANCING FLOW IN HEALTH SECTOR

OOP, and demand side financing including HEF, VHI, Voucher...Payments to Health facilities

Ministry of Economy and Finance

National Budget (1)Ministry of Health

External Donors(2)

HSSP secretariat(Pooled fund for particular

donors

Enterprise/ Patients/Targeted population

(3)

Demand side scheme (HEF, VHI, Voucher, NGOs)

(4)

National Social Security FundNSSF (5)

Provincial Health Department-(PHD)

Operational Health District(OD)

National Hospitals (NH)

Provincial Hospitals

Health Centers

Referral Hospitals

Private/NGOs providers

FLOW OF FUND INTO HEALTH SECTOR IN CAMBODIA

National Budget to MoH

Budget to subordinate

levels

National Budget to NHs

Funding Support directly to Health institutions, NGO, and community

NSSF payment to health facilities

Supply side financing

Direct support to community

HSSP Budget allocate to PHD,

OD and NGO

Direct support to OD and PHD

Demand side financing to Health facilities

Direct support to NGO

Pay premuim to VHI

Supply side financing

Funding to pool and directly to Health institutions

National Budget to NSSF

Employer and

employee pay

premium to NSSF

Budget to subordinate

levels

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4. HEALTH SPENDING ANALYSIS

4.1 TOTAL HEALTH EXPENDITURE (THE)

The Cambodian health system is financedby three main sources i.e. the Government, development partner and households’ out-of-pocket spending. It is observed that the Total Health Expenditure (THE) has substantially increased over the last five years, from USD564 Million in 2008 to USD 763 Million in 2012, or approximatelyrepresenting more than 5% of GDP. In other words, THE in 2012 itis approximately USD 52 per capita. 24% of which is from Government spending, 15% from development partner and the remaining 61% from out-of-pocket spending. Figure 2 shows the trend of the proportion of THE by sources from 2008-2012.

Table 3: Macro-economic Data 2008-2012

Source: IMF database, National Account of National Institute of Statistic2010,THE is estimated

Particular Unit Currency 2,008 2009 2010 2011 2012Gross Domestic Product (GDP) Billion Riel 41,968 43,057 47,048 52,254 57,506Gross Domestic Product (GDP) Million USD 10,337 10,400 11,634 12,856 14,266GDP, constant prices (Percent change) % 6.69 0.09 5.96 6.09 6.25Gross Domestic Product (GDP) per capita USD 760 753 830 903 987Inflation, average consumer prices( Percent change) % 25.00 -0.66 4.00 5.48 4.03Exchange rate Riel 4,080 4,180 4,053 4,050 4,050Population Million Person 13.87 14.09 14.30 14.52 14.74Poor people living uder poverty line Million Person 4.313 4.380 4.448 2.904 2.948Poverty rate (USD1) % 31% 31% 31% 20% 20%General government expenditure as percent of GDP % 16% 21% 21% 20% 19%Total government expenses Billion Riel 6,681 8,828 10,020 10,555 10,993

Current Billion Riel 3,953 4,912 5,154 6,002 6,578Capital Billion Riel 2,728 3,915 4,866 4,225 4,415

Total government expenses Million USD 1,637 2,112 2,472 2,606 2,714 Current Million USD 969 1,175 1,272 1,482 1,624 Capital Million USD 669 937 1,201 1,043 1,090

Total government expenses as % of GDP % 16% 20% 21% 20% 19%Total health expenditure Million USD 564 651 678 712 763Total health expenditure as % of GDP % 5.46% 6.26% 5.82% 5.54% 5.35%Total health expenditure per capita USD 41 46 47 49 52

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4.1.1 Government Budget Allocation and Expenditure for Health

Budget allocation

Health is highly recognized by the Government of Cambodia as one of the priority sectors for investment. In fact, the national budget allocation for health has considerably been increased over the last ten yearsandreached USD 197 Million (approximately 794 Million Riels) in 2012.As Figure 3 suggests, the 2012 national budget allocation by level is currently70% and 30% at central and provincial level, respectively. It is noted that the central allocated budget includes the budget for procurement of drug and medical consumable that are distributed and used at service delivery level.

Budget Expenditure

The national health expenditure as percentage of the approved budget is over 95% in 2012. It is reported that the total Government expenditure for health in 2012 is estimated at USD 187 Million, approximately 52,716 Riels (USD 13) per capita. This spending represents approximately 24% of THE. It is noted that the Government health expenditures as percentage of the total Government recurrent spending was at the highest level in 2010 (11.94%), followed by a slight reductionto 10.91% in 2011, but began toincrease again to 11.54% in 2012.

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Table 4: Government Budget and Expenditure for Health 2008-2012

4.1.2 Health Partner Expenditure

Financial contributions to the health sector by development partners are generally committed based on multilateral and bilateral agreements. Such funds are channeled into the health sector through different funding modalities.According to the Council for Development of Cambodia (CDC) database (accessed on the 2nd January 2013), the external spending is around 116 Million US dollars, orapproximatelyUSD 8 per capita, while health partners’ planned expenditure reported in the Health Sector Annual Operational Plan for 2012 is 141 Million US dollars, approximately USD10 per capita. The external spending for health is estimated at15% of THE in2012. Table 5: External Expenditure for Health 2008-2012

Particular Unit Currency 2,008 2009 2010 2011 2012Total Government budget for health USD 110,992,522 132,737,718 159,529,728 172,740,346 197,253,816 Total Government budget for health Million Riel 404,804 503,847 600,056 694,331 794,214

Government budget for health CENTRAL Level Million Riel 275,257 342,820 419,716 485,571 559,039 Government budget for health PROVINCIAL Level Million Riel 129,547 161,027 180,340 208,760 235,175

Government expenditure on health Million Riel 426,790 524,146 615,375 655,099 759,207Government expenditure on health CENTRAL Level Million Riel 302,383 368,083 445,469 460,695 563,579Government expenditure on health PROVINCIAL Level Million Riel 124,407 156,063 169,906 194,404 195,628

Government expenditure on health USD USD 104,605,441 125,393,660 151,832,026 161,752,840 187,458,420Government expenditure on health as % of total current govt expenditure % 10.80% 10.67% 11.94% 10.91% 11.54%Government expenditure on health as % of GDP % 1.05 1.11 1.31% 1.26% 1.31%Government expenditure on health per capita Riel 30,775 37,213 43,027 45,114 51,503Government expenditure on health per capita USD 8 9 11 12 13Government expenditure on health as % of THE % 18.95% 19.77% 22.76% 23.64% 24.57%

Particular Unit Currency 2,008 2009 2010 2011 2012External expenditure on health based on CDC database USD 110,731,129 128,290,512 107,983,969 106,811,827 116,601,457External expenditure on health per capita based on CDC database USD 8 9 8 7 8External Planned expenditure on health based on HS AOP USD 55,998,745 85,200,498 88,196,043 114,481,024 141,188,876External Planned expenditure on health per capita based on AOP USD 4 6 6 8 10External expenditure on health as % of THE % 20% 20% 16% 15% 15%

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4.1.3 Household Health Expenditure Out-Of-Pocket health expenditure (OOP) by households constitutes thelarger part of the total health expenditure. According to the latest Cambodian Social-Economic Survey (CSES), OOP expenditure on health per capita was 28 USD in 2009, excluding transportation cost for seeking care. As Figure 4 suggests, OOP has increased from USD 25 per capita in 2008 to USD 32 per capita in 2012 or approximately USD 459 billion, accounting for 61% of THE. Table 6: Household Health Expenditure 2008-2012

Particular Unit Currency 2,008 2009 2010 2011 2012Total out of pocket expenditure Billion USD 347 394 416 444 469Total out of pocket expenditure Billion Riel 1,415 1,649 1,688 1,798 1,899Out of Pocket expenditure on health per capita USD 25 28 29 31 32Out of Pocket expenditure on health per capita Riel 102,000 117,040 118,023 123,833 128,823Out of Pocket expenditure as % of THE % 61% 61% 61% 62% 61%

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5. ANALYSIS OF THE HEALTH FINANCING SCHEMES Currently, Cambodian health system is financedby both supply and demand side financing interventionsthe former include user charges with exemption for the poor, Special Operating Agency(SOA is transformed from contracting model), and subsidy. The latter includesHealth Equity Fund (HEF), Community-Based Health Insurance (CBHI), and Voucher schemes.

5.1 SUPPLY SIDE FINANCING SCHEMES

5.1.1 User Charges and Exemption for the Poor User charges together with exemption for the poor have been introduced officially at public facilities since 1996. An overall purpose of this scheme is to mobilize additional financial resources for public health facility, with its specific objectives to increase access to services by the poor, eliminate under-the-table payments, improve service quality, and increase staff motivation. Fee levels are to be set in consultation with community representatives and local authorities by taking the capacity-to-pay by a majority of the population into account. These fees are usually set below cost recovery level, thereby accommodating the community members’ ability to pay. Therefore, user charges in Cambodia are not a full cost recovery mechanism. The implementation of user fees are subject to approval of MoH, and management and use of revenue collected are subject to the Inter-Ministerial Prakas between MoEF and MoH, which states that 60% of the total fee incomes is used for staff incentives, 39% for operating costs and the remaining 1% transferred to the National Treasury. Although feeincome is a minor proportion of the total facility income, it plays a significant role for reducedunder-table payment, improved service quality and management practice, and increased financial incentives for providers. However, user charges remain a major financial barrier for access to hospital services. To date a majority of public health facilities formally implementuser charges. . The total fee income collected in 2012 is approximately at USD 19 million, excluding USD12 million generated byCalmette hospital. Exemptionfor the poor Exemption for the poor is strongly imposed with the implementation of user charges at public health facilities. By the Government policy,Tuberculosis services – from disease detection to treatment and careare free of charges for the general population.The other freely provided services include immunization for all targeted children, deworming, the provision of micronutrient (Vitamin A and Folic Acid) and ART and ARV for people living with HIV.

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In 2012, health services used with fee exemption totalled2,112,973 cases (38% used by male and 62% by female patients), and the cost of those fee-exempted cases is approximately USD 9.4 million. Loss of income due to exemption for the poor is compensated to health facilities where pro-poor health financing schemes are implemented. These schemes include subsidy, HEFs and Vouchers.

5.1.2 Special Operating Agency and Service Delivery Grant Special Operating Agency (SOAs) is laid out in the Royal Government’s Policy on Public Services Delivery and is describe as a cornerstone of the National Program for Administrative Reform. The policy provides direction to ministries on how best to improve quality and delivery of services. It calls for enhanced performance and accountability in the provision of public services through streamlining of delivery processes and making them more transparent and responsive to people’s needs. In effect, it calls for a change of paradigm within the Civil Service from that of an administrator of rules to that of a provider of public services.The purpose of SOA is to improve the quality and delivery of public services including health services.Special Operating Agency status provides public facility with a degree of autonomy in managing, and using its human and financial resources to deliver the highest possible services with improved quality in an effective way. The MoH has developed an SOA manual, which sets out the guidance on how SOAs will be implemented and managed in the public health sectors. The development of this Manual was informed bythe guidance of the Council of Administrative Reform (CAR) as set out in the “Special Operating Agencies: Implementation Guide, Performance and Accountability” document. It aims to set practical standards for the organization of SOAs, their administration, management, financial and accounting processes, reporting, monitoring and evaluation. The objectives of SOAs in the health sector are to:

1. Improve the quality and delivery of government health services in response to health needs;

2. Change the behavior of health sector staff gradually towards the principles of motivation, loyalty, service and professionalism;

3. Promote prudent, effective and transparent performance based management; and 4. Develop sustainable service delivery capacity within the available resources

In health sector, SOAs is intended to deliver health care of a good quality to Cambodians especially thepoor. To date, there are 30 SOAsestablished under the Royal Government’s Sub-degree, located in 9 provinces covering 8 provincial hospitals and 22 Operational Districts that further cover 16 referral hospitals, 291 health centers and 63 health posts. SOAs receive funds for recurrent cost from the national budget in addition to Service Delivery Grant (SDG) via Health Sector Support Project phase 2 (HSSP2). SDG is released directly from HSSP2 account to individual SOAs’ account via banking system.

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5.1.3 Government Subsidy for the Poor Key Features Subsidy scheme (SUB) has been established by the Inter-ministerial Prakas of the MoEF and MoH (No. 809, dated 13th October 2006). A main purpose of the scheme is to encourage the poor to use health services free of charges at public health facilities by providing compensation for cost of health services provided to them. MoH is responsible fordefining mechanism to identify the poor based on clear criteria and by taking equity, fairness, and transparency into account. Furthermore, MOH and other implementing institutions have to work out practical details, including tools and methods for identification of the poor patients, as well as a monitoring mechanism. Key features of SUB are illustrated in the Figure 5. Benefit packages defined by thePrakasinclude OPD and IPD at health center level, and IPD only at national hospitals, national centers and referral hospital level. Provider-payment method is basically a fixed case-based payment. Fee level (flat rate) is set according to types of services and of health facility. For instance, health center is entitled to get reimbursement of 1,000 Riel and 10,000 Riel for a consultation and hospitalization, respectively. National hospital and national health centers receive reimbursement of 80,000 Riel for a hospitalized patient regardless of disease conditions and length of stay, while 40,000 Riel, 50,000 Riel and 70,000 Riel will be reimbursed to referral hospital CPA1, CPA2 and CPA3, respectively, for a hospitalization. SUB is managed by public health facilities, namely Subsidy Operators (SUBOs) thatare entitled to receive subsidy from the Government. Practically, SUBOs are national hospitals (categorized as Group I)and operational districts (group II).

Key features of

SUBO

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Coverage Currently, the subsidy schemes are implemented in 6 national hospitals, 12 referral hospitals and 152 health centers in 12 operational districts in 8 provinces. However, according to reports provided to DPHI, there are 6 National hospitals, 11 RH and 57 HCs implementing subsidy scheme.SUBOS incorporate Health Equity Fund implementers and operators to address the specific needs of communities. Table 7 shows how SUBOs, present in 8 provinces including Phnom Penh, address community health needs through the number and spectrum of national hospitals (including CPA1, CPA2, and CPA3), referral hospitals, and health centers covered by the scheme.

Table 7: Coverage of SUBO schemes 2012

Utilization of Health Services

Table 8 indicates total utilization among referral and national hospitals, as well as among health centers throughout SUBOs 8 districts, including Phnom Penh.Health service utilization supported by SUBO is 42,792 cases in 2012. 74% of which is at referral hospitals, 22% at national hospitals, and 12% at health centers.

1 Kampong Trach Subo Government Funding Kampong Trach Kampong Trach CPA2 1 122 Angkor Chey Subo Government Funding Angkor Chey Angkor Chey CPA2 1 103 Chouk Subo Government Funding Chouk Chouk CPA2 1 16

Prey Veng 4 Kampong Trabek Subo Government Funding Kampong Trabek Kampong Trabek CPA2 1 85 Romeas Hek Subo Government Funding Romeas Hek Romeas Hek CAP2 16 Chi Pou Subo Government Funding Chi Pou Chi Pou CAP1 1

Kampong Speu 7 Kampong Speu Subo Government Funding Kampong Speu Kampong Speu CPA3 1Kampong Chhang 8 Kampong Chhang Subo Government Funding Kampong Chhang Kampong Chhang CPA3 1

9 Takmao Subo Government Funding Takmao Takmao CPA3 110 Ksach Kandal Subo Government Funding Ksach Kandal Ksach Kandal CPA1 1 11

Pailin 11 Pailin Subo Government Funding Pailin Pailin CPA2 1 0Total 7 Provinces 11 Ods 11 57

1 National Pediatric Hospital Subo Government Fudning National Pediatric Hospital National Pediatric Hospital CPA32 Ang Doung Hospital Subo Government Fudning Ang Doung Hospital Ang Doung Hospital CPA33 Khmer Soviet Hospital Subo Government Fudning Khmer Soviet Hospital Khmer Soviet Hospital CPA34 Kossamak Hospital Subo Government Fudning Kossamak Hospital Kossamak Hospital CPA35 Calmette Hospital Subo Government Fudning Calmette Hospital Calmette Hospital CPA36 MCH Subo Government Fudning MCH MCH CPA3

Total 6 National Hospital

Phnom Penh

Svay Rieng

Kandal

HEFO

Level Hospital No. RHs with HF

No.HCs with HEF

Kampot

Source of Fuding HEFIProvince No. Operational District(s) Model

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Table 8: Health Service Utilization Supported by Subsidy schemes 2012

As Figure 6shows, the average length of stay for hospitalization under SUB variesfrom 4 days to 9 days. The highest ALS isreported in Kampong Trach OD, followed by KsachKandal OD andChipou OD.

OPD IPD ALS Total OPDIPD

include delivery

ALS TotalOPD

Include Delivery

IPD ALS Total

1 Kampong Trach Kampong Trach 1,015 1,827 9 2,842 - 1,827 9 1,827 1,015 - - 1,015 2 Angkor Chey Angkor Chey 3,088 1,683 7 4,771 1,910 1,354 7 3,264 1,178 329 - 1,507 3 Chouk Chouk 2,753 960 6 3,713 1,304 960 6 2,264 1,449 - - 1,449

2 Prey Veng 4 Kampong Trabek Kampong Trabek 1,500 1,060 4 2,560 1,500 1,060 4 2,560 - - - - 5 Romeas Hek Romeas Hek 828 544 2 1,372 828 544 2 1,372 - - - - 6 Chi Pou Chi Pou 20 1,503 6 1,523 20 1,503 6 1,523 - - - -

4 Kampong Speu 7 Kampong Speu Kampong Speu 8,829 941 4 9,770 8,829 941 4 9,770 - - - - 5 Kampong Chhang 8 Kampong Chhang Kampong Chhang - 1,653 5 1,653 - 1,653 5 1,653 - - - -

9 Takmao Takmao - 2,110 6 2,110 - 2,110 6 2,110 - - - - 10 Ksach Kandal Ksach Kandal - 1,999 7 1,999 - 973 7 973 - 1,026 - 1,026

7 Pailin 11 Pailin Pailin 14 652 4 666 14 652 4 666 - - - - 18,047 14,932 5.50 32,979 14,405 13,577 5.50 27,982 3,642 1,355 - 4,997

1 Phnom Penh 1 National Pediatric HosNational Pediatric H - 2,057 4 2,057 - 2,057 4 2,057 - 2 Phnom Penh 2 Ang Doung Hospital Ang Doung Hospita - 312 - 312 - 312 - 312 - 3 Phnom Penh 3 Khmer Soviet Hospital Khmer Soviet Hosp - 505 10 505 - 505 10 505 - 4 Phnom Penh 4 Kossamak Hospital Kossamak Hospita - 447 - 447 - 447 - 447 - 5 Phnom Penh 5 Calmette Hospital Calmette Hospital - 6,245 7 6,245 - 6,245 7 6,245 - 6 Phnom Penh 6 MCH MCH - 247 4 247 - 247 4 247 -

- 9,813 6.30 9,813 - 9,813 6.30 9,813 - - 18,047 24,745 6 42,792 14,405 23,390 6 37,795 3,642 1,355 - 4,997

No. Provinces No. Operational District Operator

1

3

6

Grand totalTotal for NH

Total for OD

Total utilization Total utilization at RH/NH Total utilization HC

Kampot

Svay Rieng

Kandal

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Financing of Subsidy SUB is exclusively financed by the national budget through MOH budget. The total expenditure for 2012 is USD 469,33150% of which is spent at national hospitals, while the other49% at referral hospitals and the remaining 1% at health centers. Details can be seen in Table 9.

Table 8: Financial Information of Subsidy scheme 2012

5.2 DEMAND SIDE FINANCING SCHEMES Removing financial barrier in access to and utilization of health services by the poor and near poor remains a major issue of concern in Cambodia. In this regard, the MoH has implemented to various demand side financing schemes; namely Health Equity Funds (HEF) and Voucher scheme, and supported Community Based Health Insurance (CBHI). The coverage of theseschemes has gradually been expanded within financial resources and technical assistance made available by both the Government and health partners.

OPDIPD

including Delivery

Total Direct OPDIPD

including Delivery

Total Direct OPDIPD

including delivery

Total Direct

1 Kampong Trach Kampong Trach - 23,500 23,500 - 23,500 23,500 - - - 2 Angkor Chey Angkor Chey 213 16,925 17,138 213 16,925 17,138 - - - 3 Chouk Chouk 67 10,728 10,794 67 10,728 10,794 - - -

2 Prey Veng 4 Kampong Trabek Kampong Trabek - 14,118 14,118 - 14,118 14,118 - - - 5 Romeas Hek Romeas Hek - 6,800 6,800 - 6,800 6,800 - - - 6 Chi Pou Chi Pou - 15,030 15,030 - 15,030 15,030 - - -

4 Kampong Speu 7 Kampong Speu Kampong Speu - 16,468 16,468 - 16,468 16,468 - - - 5 Kampong Chhang 8 Kampong Chhang Kampong Chhang - 28,928 28,928 - 28,928 28,928 - - -

9 Takmao Takmao - 36,943 36,943 - 36,943 36,943 - - - 10 Ksach Kandal Ksach Kandal - 12,297 12,297 - 9,730 9,730 - 2,567 2,567

7 Pailin 11 Pailin Pailin 4 8,150 8,154 4 8,150 8,154 - - - Total for OD 11 283 189,884 190,167 283 187,318 187,601 - 2,567 2,567

1 Phnom Penh 1 National Pediatric HospitaNational Pediatric Hospital - 41,140 41,140 - 41,140 41,140 - 2 Phnom Penh 2 Ang Doung Hospital Ang Doung Hospital - 6,240 6,240 - 6,240 6,240 - 3 Phnom Penh 3 Khmer Soviet Hospital Khmer Soviet Hospital - 10,100 10,100 - 10,100 10,100 - 4 Phnom Penh 4 Kossamak Hospital Kossamak Hospital - 8,940 8,940 - 8,940 8,940 - 5 Phnom Penh 5 Calmette Hospital Calmette Hospital - 207,804 207,804 - 207,804 207,804 - 6 Phnom Penh 6 MCH MCH - 4,940 4,940 - 4,940 4,940 -

Total for NH 6 - 279,164 279,164 - 279,164 279,164 - - - Grand total 283 469,048 469,331 283 466,481 466,764 - 2,567 2,567

Total cost (USD) Total cost_RH Total cost_HC

Operational District Operator

1

3

6

Kamport

Svay Rieng

Kandal

No. Provinces No.

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5.2.1 Health Equity Funds Key Features Health Equity Funds is a pro-poor health financing mechanism and widely recognized as asocial-transfer mechanism. HEFs aredesigned to reimburse a full or partial cost of health services provided to the poor at public health facilities. This involves the poor swhoare entitled as HEFs beneficiaries,using health services as they need free of charge. Usually, HEFs’ beneficiaries are entitled by the process of pre-identification of the poor (community-based assessment), but post identification or health facility-based assessment remains conducted for those who access health facilities and claim themselves without identification of this status, usually through ID poor. Benefit packages covered by HEFs include reimbursement for medical services and other associated costssuch as transportation cost, allowances for a patient’s care-taker, funeral cost and referral cost. Provider payment method is based on standardized rate as approved by MoH letter No.10-12HSSP2, dated 12th December 2012. Contractual arrangements are a basis for HEF management and implementation. HEFs aremanaged by HEFs Implementers (HEFI) and operationalized by HEF Operators (HEFO). Selection of HEFIsand HEFOs is a competitive and open bidding process that is handled by MOH (HSSP2 Secretariat and DPHI). HEFIs and HEFO are currently not-for-profit NGOs.

Geographical Coverage To date, 45HEF schemeshave beenimplemented in 45 ODs in 23 provinces through contract arrangements with 47 RHsout of 89 RHs in total, and with 313 HCsout of 1,024 HCs in total. 44 RHs and 281 HCs are financed by pooled funds, which include RGC counterpart fund, under HSSP2, and other 3 RHs and 32 HCs are financially supported by UNICEF, URC and Swiss Red Cross. The Table 10 provides more information about the current geographical coverage of HEFs, HEFI and HEFO, as well as funding sources and facilities where HEFs are implemented.

Population Coverage

HEFs currently protect an estimated 2.45 million identified poor. In other words, the proportion of the poor living under the national poverty line (national average 31% in 2007) supported by HEFs has increased significantly from 11% in 2008 to 21% in 2009 and reached 35% in 2010. To date poverty rate is estimated at 20% (draft by Ministry of Planning), HEF coverage was therefore estimated around 71% of target population in 2011, and up to 76% in 2012. The Ministry of Health has planned to expand HEFs program to reach its full coverage in 2015. Utilization of Health Services

It is noted that HEFs have increased the utilization of health services in both OPD and IPD by the poor over the period from 2008 to 2012. In fact, the total number of OPD cases has increased from 8,972 in 2008 to 68,183 cases in 2011 and up to 1,176,116 cases in 2012. The

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level of health services utilization is higher at HC up to 72% against 28% at referral hospitals. Table 11 illustrates the level of health service utilization by health facility with HEFs’ support.

Table 10:HEFs Coverage, Funding Sources and HEFI/HEF

1 Mongkol Borei HEF HSSP2 URC-CHS PFD CPA3 2 19

2 O'Chrov HEF HSSP2 URC-CHS PFD CPA2 1 11

3 Preah Net Preah HEF HSSP2 URC-CHS PFD CPA1 1 13

4 Battambang HEF HSSP2 URC-CHS PFD CPA3 1 23

5 Sangke HEF HSSP2 URC-CHS PFD 0 15

6 Mong Russey HEF HSSP2 URC-CHS PFD CPA2 1 13

7 Sampov Luon HEF HSSP2 URC-CHS PFD CPA1 1 0

8 Smach Meanchey HEF HSSP2 URC-CHS RHAC CPA3 1 4

9 Sre Ambel HEF HSSP2 URC-CHS RHAC CPA1 1 5

Rattanakiri 10 Banlung HEF HSSP2 URC-CHS AFH CPA2 1 0

Mondolkiri 11 Senmonorom HEF HSSP2 URC-CHS AFH CPA2 1 0

12 Kampong ThomLinkage

HEF& CBHIHSSP2 URC-CHS AFH CPA3 1 21

13 Stong HEF HSSP2 URC-CHS AFH CPA2 1 0

14 Tbong Kmum RPH HSSP2 URC-CHS RHAC CPA2 1 13

15 Ponhea Krek HEF HSSP2 URC-CHS RHAC CPA1 1 0

16 Memut HEF HSSP2 URC-CHS RHAC CPA2 1 0

17 Prey Chhor/Kang Meas HEF HSSP2 URC-CHS AFH CPA1 1 3

18 Chamkar Leu /Stung Trang HEF HSSP2 URC-CHS AFH CPA1 1 3

19 Choeung Prey - Batheay HEF HSSP2 URC-CHS AFH CPA1 1 3

20 Kampong Cham - Kampong Siem HEF HSSP2 URC-CHS AFH CPA3 1 0

21 Siem Reap HEF HSSP2 URC-CHS AFH CPA3 1 0

22 Sotnikum HEF HSSP2 URC-CHS AFH CPA2 1 0

23 Kralanh HEF HSSP2 URC-CHS CHC CPA2 1 0

Oddar Meanchey 24 Samroang HEF HSSP2 URC-CHS CHC CPA2 2 0

25 Kandal HEF HSSP2 URC-CHS FHD CPA3 3 1

26 Choeung HEF HSSP2 URC-CHS FHD CPA1 0 2

27 Lech HEF HSSP2 URC-CHS FHD CPA1 1 1

28 Tbong HEF HSSP2/ USAI URC-CHS CBO CPA1 1 4

29 Kampong Chhnang HEF HSSP2 URC-CHS RHAC/OD CPA3 1 15

30 Kampong Tralach RPH HSSP2 URC-CHS RHAC CPA1 1 11

31 Boribo RPH HSSP2 URC-CHS RHAC CPA1 1 11

32 Kirivong HEF HSSP2 URC-CHS BFH CPA2 1 20

33 Ang Roka HEF HSSP2 URC-CHS BFH CPA1 1 10

Preah Vihear 34 Thbeng Meanchey HEF HSSP2 URC-CHS AFH CPA3 1 0

35 Pearaing HEF HSSP2 URC-CHS AFH CPA2 1 0

36 Preah Sdach HEF HSSP2 URC-CHS AFH CPA1 1 0

Sihanouk 37 Sihanouk HEF HSSP2 URC-CHS BFH CPA3 1 12

38 Kratie HEF HSSP2 URC-CHS AFH CPA3 1 0

39 Chhlong HEF HSSP2 URC-CHS AFH CPA2 1 4

40 Sampov Meas HEF HSSP2/ USAI URC-CHS PFD CPA3 1 22

41 Bakan HEF HSSP2 URC-CHS PFD CPA2 1 10

Kampot 42 Kampot Linkage

HEF& CBHI

HSSP2-GIZ & AusAID

SKY (Jan-Jun 12)AFH (Jul-Dec 12)

CPA3 1 12

44 281

Svay Rieng 1 Svay Rieng HEF Unicef Unicef Svay Rieng CPA3 1 0

Siem Reap 2 Angkor Chhum HEF URC URC-CHS STSA CPA1 1 17

Takeo 3 Daun Keo HEF SRC SRC BFH CPA3 1 15

3 32

47 313

Total of HEF UNICEF and SRC

Grand Total

Battambang

Province No. Operational District(s) Model HEFO

Takeo

Prey Veng

Kratie

Pursat

Koh Kong

Kampong Thom

Kampong Cham

No.HCs with

Banteay Meanchey

Source of Fuding

HEFI

Total of HEF HSSP

Siem Reap

PP. Municipal

Kampong Chhnang

Level Hospital No. RHs with HF

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Table 11:Health Services Utilization Supported by HEFs in 2012

OPD IPD Delivery ALS Total OPDIPD

include delivery

Delivery ALS TotalOPD

Include Delivery

IPD Delivery Total

1 Mongkol Borei PFD 48,502 6,325 1,139 9 54,827 2,818 6,325 633 9 9,143 45,684 506 45,6842 Poi Pet PFD 27,792 3,735 598 5 31,527 8,959 3,735 420 5 12,694 18,833 178 18,8333 Preah Net Preah PFD 31,762 1,764 569 6 33,526 4,545 1,764 150 6 6,309 27,217 419 27,2174 Moung Russei AFH 74,739 3,680 1,614 5 78,419 2,873 3,680 780 5 6,553 71,866 834 71,8665 Sampov Luon PFD 16,193 3,114 840 6 19,307 1,524 3,114 396 6 4,638 14,669 444 14,6696 Battambang AFH 89,683 8,237 1,962 7 97,920 12,121 8,237 1,008 7 20,358 77,562 954 77,5627 Sangkae AFH 64,414 575 767 4 64,989 9,364 575 11 4 9,939 55,050 756 55,0508 Chamkar Leu AFH 5,543 3,527 463 4 9,070 55 3,527 366 4 3,582 5,488 97 5,4889 Choeung Prey AFH 14,361 2,811 438 6 17,172 231 2,811 266 6 3,042 14,130 172 14,130

10 Kampong Cham AFH 1,517 6,899 667 8 8,416 1,517 6,899 667 8 8,416 0 0 011 Memut RHAC 6,856 3,350 428 5 10,206 123 3,350 360 5 3,473 6,733 68 6,73312 Ponhea Krek RHAC 6,176 3,732 343 5 9,908 2,095 3,732 208 5 5,827 4,081 135 4,08113 Prey Chhor AFH 6,112 2,343 271 4 8,455 5 2,343 140 4 2,348 6,107 131 6,10714 Tbong Khmum-Kroch Chhmar RHAC 32,317 4,034 518 6 36,351 28 4,034 319 6 4,062 32,289 199 32,28915 Kampong Chhnang RHAC 29,107 4,935 1,485 6 34,042 5,772 4,935 796 6 10,707 23,335 689 23,33516 Kampong Tralach RHAC 32,184 1,601 952 4 33,785 119 1,601 278 4 1,720 32,065 674 32,06517 Boribo RHAC 33,314 813 724 4 34,127 66 813 166 4 879 33,248 558 33,24818 Kampong Thom AFH 35,945 3,423 418 6 39,368 10,898 3,423 377 6 14,321 25,047 41 25,04719 Stong AFH 1,618 1,686 415 6 3,304 1,618 1,686 415 6 3,304 0 0 020 Smach Mean Chey RHAC 8,181 1,938 323 5 10,119 5,934 1,938 323 5 7,872 2,247 0 2,24721 Srae Ambel RHAC 11,069 1,915 469 4 12,984 2,477 1,915 408 4 4,392 8,592 61 8,59222 Chhlong AFH 11,855 2,827 380 5 14,682 3,961 2,827 342 5 6,788 7,894 38 7,89423 Kratie AFH 81 4,317 647 7 4,398 81 4,317 647 7 4,398 0 0 0

8 Mondulkiri 24 Senmonorum AFH 0 2,683 72 6 2,683 0 2,683 72 6 2,683 0 0 0

9Oddar Meanchey

25 Samraong CHC 2,491 4,018 264 5 6,509 2,491 4,018 264 5 6,509 0 0 0

26 Cheung FHD 14,915 280 204 10 15,195 278 280 0 10 558 14,637 204 14,63727 Kandal FHD 23,445 5,332 650 10 28,777 20,542 5,332 650 10 25,874 2,903 0 2,90328 Lech FHD 5,424 431 96 3 5,855 5,424 431 96 3 5,855 0 0 029 Tbong FHD/KCHP 12,068 1,108 180 4 13,176 6,349 1,108 146 4 7,457 5,719 34 5,719

11 Preah Vihear 30 Tbeng Meanchey AFH 2,037 4,946 181 6 6,983 2,037 4,946 181 6 6,983 0 0 031 Peareang AFH 394 2,383 190 6 2,777 394 2,383 190 6 2,777 0 0 032 Preah Sdach AFH 1 2,558 178 5 2,559 1 2,558 178 5 2,559 0 0 033 Bakan PFD 27,577 1,249 609 6 28,826 920 1,249 122 6 2,169 26,657 487 26,65734 Sampov Meas PFD 62,326 2,886 1,652 7 65,212 14,421 2,886 766 7 17,307 47,905 886 47,905

14 Ratanakiri 35 Banlung AFH 72 2,100 68 6 2,172 72 2,100 68 6 2,172 0 0 036 Kralanh CHC 602 1,036 103 10 1,638 602 1,036 103 10 1,638 0 0 037 Siem Reap AFH 9,343 3,783 78 10 13,126 9,343 3,783 78 10 13,126 0 0 038 Sot Nikum AFH 6,767 2,397 149 7 9,164 6,767 2,397 149 7 9,164 0 0 0

16 Sihanouk Ville 39 Sihanouk Ville BFH 31,992 4,541 1,137 6 36,533 1,142 4,541 769 6 5,683 30,850 368 30,85040 Kirivong BFH 46,587 2,783 576 5 49,370 3,772 2,783 31 5 6,555 42,815 545 42,81541 Ang Rokar BFH 44,899 4,399 834 5 49,298 6,469 4,399 379 5 10,868 38,430 455 38,430

18 Kampot 42 Kampot SKY & AFH 16,217 547 82 5 16,764 1,685 547 37 5 2,232 14,532 45 14,532 Total 896,478 127,041 23,733 6 1,023,519 159,893 127,041 13,755 6 286,934 736,585 0 9,978 736,585

Utilization supported by others1 Svay Rieng 1 Svay Rieng Svay Rieng 2119 1104 215 4 3223 2119 1104 215 3.97 3223 0 0 02 Siem Reap 2 Angkor Chhum STSA 84032 153 1088 4 84185 541 153 11 4.30 694 83491 1077 834913 Takeo 3 Daun Keo BFH 7895 7339 746 1 15234 7895 7339 746 1.47 15234 0 0 0

Total 94046 8596 2049 3 102,642 10555 8596 972 3.25 19151 83491 0 83491Grand total 990,524 135,637 25,782 5 1,126,161 170,448 135,637 14,727 5 306,085 820,076 0 9,978 820,076

17 Takeo

12 Prey Veng

13 Pursat

15 Siemreap

6 Koh Kong

7 Kratie

10 Phnom Penh

3 Kampong Cham

4Kampong Chhnang

5Kampong Thom

Total utilization at RH Total utilization HC

1Banteay Meanchey

2 Battembang

No. Provinces No. Operational District Operator

Total utilization

Page 24 of 39

Average Length of Stay (ALS) of HEF patients was around 5 days similar to an overall ALS at public hospitals. However a large variation in ALS was observed between schemes; the longest ALS was 10 days in 4 ODs followed by 9 days in one OD (see below Figure 7).

Financing HEFs

In 2012, the total HEF expenditure is USD 9,457,954. 85% of which is spent for direct benefit to the poor patients and other 15% for management and operational of the schemes. Spending for direct benefits is mostly for IPD (50%), followed by 24% for OPD, then 15% for transportation and 10% for food allowance (see Figure 8)

It is noted that 42 HEFs schemes out of 45 schemes in total are funded by HSSP2 pooled funds, in which the Government shared 30% of the total cost reimbursed for direct benefit and HSSP2 partners financially contributed the remaining 70%. In 2012, the total expenditure funds for HEF reimbursed by HSSP2 was around USD 9.19 million, USD7.72 Million (84%) of which was spent for direct benefit (medical cost and non-medical benefits such as transportation, food, cash), and USD 1.45 (16%) for operating cost.Figure 9 shows share of HEFs expenditure for direct benefit and management cost, and Figure 10 indicates HEFs expenditure by cost category.

According to cost analysis, HEFs co-financed by RGC and HSSP2 partners paid on average USD 8.40 per caseto HC and USD 29.32 per caseto referral hospital. These costsincludedirect benefit cost (medical cost and non-medical cost) and management cost. In term of medical benefit, HEF reimburses on average USD1.01 per OPD case at HC and USD 6.44 per OPD case

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at RH, and USD29.24 per IPD case at referral hospital. HEFs also paid for non-medical benefit (transportation cost, referral, foods, allowances for a caretaker, and funeral) around USD6.57 per case at RH and USD0.07 per case at HC. More information is provided in Table 12.

Table 12: HEF’s expenditure by levels of health facilities 2012

It is noted that 89% of the total HEF direct cost (USD 7,967.377) was paid for, referral hospital services used by HEFs beneficiaries and only 11% for health center services.

5.2.2 Voucher Scheme for Reproductive Health Services

Key Features

To reduce maternal mortality in Cambodia, the Ministry of Health has introduced a set policy and strategic interventions including the National Strategy for Reproductive and Sexual Health and Road map for Accelerating Maternal and Child Mortality. A voucher for Reproductive Health project has been designed to support the country efforts in reducing maternal mortality and the implementation of the above-mentioned interventions. Theproject is a financial component of Social Health Protection Program (SHP) in Cambodia under Cambodian-German cooperation.

Identified poor women (by pre-ID poor) are beneficiaries of the voucher project. “Vouchers” are distributed to those poor women by voucher promoters. The vouchers entitle them to use reproductive health service at contracted public and private health facilities.

Benefit packages covered by the voucher include ANC, delivery, PNC, family planning and safe abortion (for all women). The voucher also reimburses transportation cost and hospital services at referral hospitals, where HEFs are not available.

The vouchers are managed by Voucher Management Agency (VMA) and operated by voucher operator via contractual schemes arrangements with MOH.

Particular RH HC TotalExpenditure for medical benefit OPD 1,096,872 825,523 1,922,395 Expenditure for medical benefit IPD 3,977,202 3,977,202 Expenditure for non-medical benefit 2,010,045 57,735 2,067,780 Total expenditure for direct cost 7,084,120 883,258 7,967,377 Total expenditure for administration 1,490,577 Grand total 7,084,120 883,258 9,457,954 Utilization_OPD 170,448 820,076 990,524 Utilization_IPD 135,637 - 135,637 Total utilization 306,085 820,076 1,126,161 Medical cost per OPD cases 6.44 1.01 1.94Medical cost per IPD cases 29.32 29.32Non-medical cost per case 6.57 0.07 1.84Total direct cost per case 23.14 1.08 7.07Total cost per case 23.14 1.08 8.40

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Geographical Coverage

The voucher schemes have been implemented since 2011. To date the schemes have contracted with 5 referral hospitals and 118 HCs in 9 ODs in 3 provinces and with 4 private clinics for providing safe abortion services (Table 13 below). Table 13: Geographical coverage voucher scheme 2012

Population Coverage

Currently, voucher scheme covers an estimated 107,763 women of reproductive age from 15-49 years-oldin those 9 ODs (Table 14).

Table 14: Population coverage by voucher schemes 2012

Utilization of Health Services

Total utilization of reproductive health services supported by the voucher project in 2012 was 36,299 cases, mostly at health centers (85%), followed by 10% at private clinics and4% at referral hospitals. Table 15 provides detailed information about utilization of reproductive services in 2012 by location, including funding sources and voucher operator.

No. Provinces Operational Districts

No. Provincial Name OD Name Int. NGO Local NGO Sources Start End RH HC Clinic

1 Kampong Thom Kampong Thom (MSI clinic) EPOS AFH KFW Jan-12 0 20 1

Staung EPOS AFH KFW Jan-12 0 8

Baray and Santuk (Ms Sim clinic) EPOS AFH KFW Jan-12 1 19 1

2 Kampot Angkor Chey EPOS AFH KFW Jan-12 1 10

Chhouk EPOS AFH KFW Jan-12 1 16

Kampong Trach EPOS AFH KFW Jan-12 1 12

OD Kampot EPOS AFH KFW Jan-12 1

3 Prey Veng Kampong Trabek EPOS AFH KFW Jan-12 1 8

Pearaing EPOS AFH KFW Jan-12 0 16

Preah Sdach EPOS AFH KFW Jan-12 0 9

Svay Rieng Chipou (Clinic MSI) EPOS AFH KFW Jan-12 1

5 118 4TOTAL

Implementing Agency Budget (USD) Year Facility covered

No Province ODtargeted

populationKampong Thom 21,650

Baray Santok 20,254

Stong 11,043

Angko Chey 5,724

Chhouk 8,465

Kampong Trach 8,179

Pearaing 13,928

Preah Sdach 9,106

Kampong Trabek 9,413

107,762 Total

Kampong Thom

Kampot

Prey Veng

1

1

1

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Financing of Voucher Schemes

The voucher project is financed by KFW as a grant. Total expenditure, including direct cost and indirect cost is USD 626,360,63% of which was spent for direct cost and 37% for indirect cost. Table 16 provides detailed information about expenditure in 2012.

The operating costs of these schemes are extremely high and range between 20% and 57%- The highest operating cost (indirect cost) were the schemes operating in OD Stong and OD Pearaing (both 57%), followed by Preah sdech (47%), whereas the lowest operating cost was the scheme in Kg. Thom and Angkor Chey ODs (20% and 31%, respectively) (Figure 11). Similarly, total direct benefit costs range from 43% (Stong and Peareang, respectively) to 80% (Kampong Thom).

FP SA Delivery Other Total FP SA Total FP SA Delivery Other Total FP SA Delivery Other Total1 Baray Santouk KFW EPOS AFH 45 52 82 1 180 255 86 341 460 213 563 2,619 3,855 760 351 645 2,620 4,3762 Kg Thom KFW EPOS AFH 0 0 0 0 0 993 1,924 2,917 460 0 175 1,445 2,080 1,453 1,924 175 1,445 4,9973 Stong KFW EPOS AFH 0 0 0 0 0 0 0 0 588 0 297 2,304 3,189 588 0 297 2,304 3,1894 Angkor Chey KFW EPOS AFH 0 171 66 0 237 0 0 0 1,184 507 384 2,393 4,468 1,184 678 450 2,393 4,7055 Chhouk KFW EPOS AFH 0 96 114 1 211 0 0 0 941 120 496 2,274 3,831 941 216 610 2,275 4,0426 Kampong Trach KFW EPOS AFH 0 51 81 0 132 0 0 0 988 262 381 2,092 3,723 988 313 462 2,092 3,8557 Kampot OD (RH Kampo KFW EPOS AFH 0 168 93 0 261 200 227 427 0 0 0 0 0 200 395 93 0 6888 Kampong Trabek KFW EPOS AFH 27 14 182 4 227 0 0 0 686 0 456 2,357 3,499 713 14 638 2,361 3,7269 Peareang KFW EPOS AFH 0 0 0 0 0 0 0 0 529 22 390 1,423 2,364 529 22 390 1,423 2,364

10 Preash Sdach KFW EPOS AFH 0 0 0 0 0 0 0 0 831 0 523 2,841 4,195 831 0 523 2,841 4,1954 Svay Rieng 11 Chipou KFW EPOS AFH 0 0 0 0 0 136 26 162 0 0 0 0 0 136 26 0 0 162

Table 15: UTILIZATION SUPPORTED BY VOUCHER_2012

3 Prey Veng

No. Province No. Operational District Funding Source HEFIUtilization at HC Total Utilization

1 Kg Thom

2 Kampot

OperatorUtilization at RH MSI, RHAC and Chheng Sim

FP SA Delivery

ANC1-4, PNC1-2 and Miscarriage

(SMH)

Transport FoodOther costs

(SMH)Total Direct Benefit Cost

Admin. Equipment TAProgram

developmentPre ID

Total indirect

cost

1 Baray Santouk AFH 7,621.25 8,335.00 9,940.00 3,802.00 6,034.50 3,192.63 4,321.75 43,247.13 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 68,738.75

2 Kg Thom AFH 20,995.75 43,065.00 2,525.00 2,093.50 31,739.25 1,542.73 1,198.40 103,159.63 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 128,651.25

3 Stong AFH 1,864.75 350.00 4,140.00 3,209.50 5,163.75 2,004.15 2,538.30 19,270.45 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 44,762.07

4 Angkor Chey AFH 10,418.75 16,843.33 8,675.00 3,522.50 9,962.92 3,922.73 3,211.13 56,556.36 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 82,047.98

5 Chhouk AFH 5,080.00 7,073.33 10,860.00 3,140.00 11,252.92 4,166.93 4,316.08 45,889.26 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 71,380.88

6 Kampong Trach AFH 9,025.00 8,508.33 8,815.00 2,996.50 8,008.54 3,697.91 3,354.00 44,405.28 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 69,896.91

7 Kampong Trabek AFH 5,967.88 532.50 10,480.00 3,203.00 6,884.13 4,800.00 4,561.48 36,428.98 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 61,920.60

8 Peareang AFH 3,145.25 500.00 5,200.00 1,990.50 3,192.63 1,934.43 2,984.78 18,947.58 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 44,439.20

9 Preah Sdach AFH 3,645.38 232.50 7,015.00 3,999.00 6,582.13 3,595.40 3,962.15 29,031.55 16,980.13 109.07 0.00 6,100.97 2,301.45 25,491.62 54,523.17

Total 67,764.00 85,440.00 67,650.00 27,956.50 88,820.75 28,856.90 30,448.05 396,936.20 152,821.21 981.62 0.00 54,908.72 20,713.08 229,424.62 626,360.82

Table 16: Total expenditure of voucher scheme by OD_2012Total Direct benefit Cost (USD) Indirect Cost (USD)

Total Cost (USD)

No. Operational District Operator

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The figure 12 below shows that vouchers were most spent at HCs, corresponding to high level of utilization of HC services (75%). It is interesting to note that the voucher project provided close to 90% of the total amount of reimbursements for safe abortion services used at private clinics in Kompong Thom.

5.2.3 HealthInsurance Moving toward universal health coverage is a long journey for Cambodia. Social health insurance is at a very early stage of development. In the Cambodian context,a pathway to universal health coverage will reachthrough multiple approaches. Such approaches include:

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• Social assistance schemes for the poor and vulnerable - such as health equity funds,

conditional cash transferetc. • Compulsory health insurance for formal sector, covering civil servants and salaried

workers in private sector; • Voluntaryhealth insurance for informal sector through the development of community-

based health insurance schemes. 5.2.4 Social Health Insurance Two types of Compulsory Health Insurance scheme have been developed and implemented: National Social Security Funds (NSSF) and National Social Security Funds for Civil Servant (NSSFC).

(1) Ministry of Labor and Vocational Training (MOLVT) is responsible for the development of compulsory social security and health insurance for private-sector salaried workers as stipulated under the Social Security Law (2002). The law articulates, among the others, the establishment of the Social Security Organization and the provision of a work injury program and old age pensions.

NSSF was established by the Government’s Sub-decree No. 16, dated 2nd March 2007, pursuing the following objectives:

• To manage and administer the social security schemes; • To ensure provision of all benefits to members to support income security in case of

any contingency such as old age, invalidity, death, occupational risks, and others; • To collect contributions from its members and employers; • To facilitate and organize provision of health and social services for the members; • To cooperate with organizations concerned to educate and promote methods of

occupational risk prevention, take measures on health and safety at work places, and study and investigate occupational diseases; and

• To manage the investment of social security funds.

NSSF is overseen by a Governing Board, comprising of representatives of MoLVT, MoEF, Council of Administrative Reform, MoH, Unions and Employers associations, and executed by Director. Employment Injury scheme has been implemented since 2008. According to Social Security Law,private enterprises employing 8 workers and more have to register with NSSF. The premium is 0.8% of gross salary, 0.5% and 0.3% of which was contributed byemployers and the Government, respectively. Since 2011, the contribution of 0.8% has been made by employers only. It is reported that the premium varies from a minimum level of 1,600 riels to a maximum level of 8,000 riels per month. Up to 2012, 4,583 enterprises were registered with NSSF, and

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86.7% of those enterprises (3,921 enterprises)paid contribution for 745,275 employees.The expansion was made from three provinces in 2008 to 20 provinces included Phnom Penh Municipality.A health insurance scheme is planning to be implemented in 2013.

(2) Ministry of Social Affairs, Veterans and Youth (MOSVY), which is responsible for the development of social security for civil servants, has recently drafted a sub-decree on the provision of pensions, occupational injury and other benefits including maternity and sick leave. The RGC Sub-Decree on the Establishment of National Civil Servant Social Security Fund (NCSSF) adopted in February 2008 paves the way for the “Creation of an Institution of Public Administration with the Mission to provide Social Security Services to the Public, and manage Social Security Benefits to Civil Servants and their Dependents”.

The NSSFC was officially established in February 2009.

5.2.5 Voluntary Health Insurance Schemes Voluntary health insurance refers to community based health insurance (CBHI),which is designedbased onthe principlesof risk pooling and pre-payment and arenon-for-profit schemes and run by NGOs. Premiums are sold at a low-costto community members, who are willing to register with the schemes. Insured personsandtheir family are entitled to use the defined health servicesat contracted public health facilities i.e.health centers and referral hospitals. The CBHI operator reimbursesthose facilities for the cost of services consumed by its members. Geographical coverage To date, 19 CBHI schemes have been implemented in 19 ODs in 11 provinces via contracts with231 Health Centers, 18 RHs (5 CPA1, 4 CPA2, and 8 CPA3) and 1 National Hospital. Provider payment methods are mixed according to design of each individual scheme. Those include fee-for-service, case base payment and capitation. Table 17provides key information about CBHI schemes.

Work Injuries Scheme 2008-2009 2010 2011 2012No. of province and PP 3 8 13 20Coverage of enterprises 884 1,564 2,429 3,921 Coverage of membership (enterprise/employees) 340,840 530,599 594,458 745,275

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Table 17: Coverage of CBHI 2012

Appreciations: (SKY) SokhapeapKrousaYeung, (BfH) Buddhism for Health, (CAAFW) Cambodian Organization for Assistance to families and Widows, (PFD) Poor Family Development , (CHHRA): Cambodia Health and Human Rights Alliance, (CHO) Cambodian Health Organization, (RACHA) Reproductive and Child Health Alliance, (HNI) Health Net International, (URC) University Research co llc., (STSA) SamakumTheanearabrongSokhapheap (The scheme being managed by the commune council). Population coverage It is noted that the number of schemes has increased from 18 in 2011 to 19 in 2012. In contrast, the total members, who enrolled with those schemes, have decreased from 297,687 in 2011 to around 166,663 in 2012. Following a steady increase between 2008 and 2011, this means that the average dropout rate is high 5% (see figure 13 and 14 below).

1 Banteay Meanchey 1 CAAFWFeb, 2005 1 Thmar Pouk

10Case Thmor Pouk RH

CaseMonkol Borey

Hospital

2Oddar Meanchey 2 CAAFW

January, 2009 2 Samrong19

case Anlong Veng Case Samrong

3 Kampong Thom 3AFH January, 2010 3 Kampong Thom

21Formular linkage

Privincial hospital Case based + User Fees

Siem Reap 4 CHC Januray, 2011 4 Siem Reap 22 Case Provincial Hospital Case

Siem Reap 5STSA August, 2010 5 Angkor Chum

17 Case

Angkor Chhum and Puok RH Case

Siem Reap RH and Khmer Soviet

5 PP. Municipal 6 SKY

Dec, 2006 6 Phnom Penh

2

Fee

Chamkar Morn, Pochentong, Tuo Scay Prey, Samdach Ov, Khmer Soviet

Hospital

Fee Lumpsum Kosamak

Takeo 7 SKY 2001 7 Ang Roka 10 Capitation Ang Roka RH Capitation Takeo Hospital

Takeo 8 SKY 2008 8 Daun Keo 15 Capitation Takeo RH Case

Takeo 9 SKY 2010 9 Bati 13 Capitation Takeo RH Case

Takeo 10 SKY 2010 10 Prey Kabass 14 Capitation Takeo RH Case

Takeo 11 BFH January, 2006 11 Kirivong 21 Capitation Kirivong RH Capitation Takeo RH

7 Kandal 12 SKY 1998 12 Ta Khmoa CapitationChey Chum Neah Hospital

Fee Lumpsum Kosamak

8 Kampot 13 SKY 2008 13 Kampot 12 CapitationKampot Hospital

Capitation

9 Prey Veng 14 RACHA/HN July, 2010 14 Pearaing 10 Capitation Pearaing RH Case based khmer Soviet

Pursat 15 PCHSFA January, 2012 15 Bakan 10 Flat Rate Bakan RH Flat Rate

Pursat 16 PCHSFA August, 2011 16 Sampov Meas 22 Flat Rate Pursat RH Flat Rate

Battambang 17 CHO October, 2009 17 Battambang 9 Case Battambang

Battambang 18 CHO Januray, 2010 18 Sangke 3 Case Battambang

Battambang 19 CHO March, 2012 19 Thma Kol 1 Case Thmar Koul

Total 18 231

10

11 Case

6

Secondary Referal

4

No. HC with CBHI

Payment Model to HC

Primary Referal Hospital

Payment Model to RHs

Operational District(s)

No Province No. Scheme Start date No.

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From Figure 15below, it is noted that CAAFW in ThmorPouk OD, Banteay Mean Chey province and Samrong OD in Ordor Mean Chey province have highest memberships (40,627 and 31,075 persons, respectively), and account for almost half of CBHI membership in the country.

CBHI Revenue The income of CBHI scheme is estimated around USD 656,806 in 2012. On average only 28 % came from premiums paid by members while majority of income (72%) came from other sources, mainly donor funding. It is observed that only a few CBHI schemes can operate by relying solely on premiums; other schemes, especially those with high membership, must use other subsidies to support their function. Figure 16 below identifies the importance of premiums as a significant funding source for CBHI scheme’s viability.

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CBHIExpenditure As Figure 17 indicates, the total expenditure in 2012 was USD 622,715 with 46% spent for medical fee, 34% for administrative cost, and 10% for transportation cost of patients, 4% for outreach and marketing and 2% for other cost.

0%20%40%60%80%

100%

Figure 16: income of CBHI by sources 2012

Income of Premiums Others Income

Total direct medical benefits

paid46%

Total non-medical

benefits paid10%

Administrative costs34%

Outreach and social marketing

costs8%

Other costs2%

Figure17: Proportion of expenditure 2012

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Table 18: Total income and expenditure of CBHI in 2012 (US)

Figure 18 bellow shows variability between ODs in CBHI patients’ average length of stay. The average length of stay (ALS) of CBHI patients was estimated to around 4.77 days. However, it is observed that ALS among CBHI patients was longest in Siem Reap OD (7days) compared to other ODs, which were around 4 and 5 days. Zero days means not shown in report.

Total Premiums Collected Others Income Total

Income(USD)

Total direct medical benefits

paid

Total non-medical benefits

paid

Administrative costs

Outreach and social marketing

costsOther costs Total Expenditure

1 Thmar Pouk 49,269 174,223 223,492 78,558 13,446 61,908 19,744 6,604 180,260 2 Samrong 46,963 198,506 245,469 86,570 22,610 68,497 20,829 - 198,506

AFH 3 Kampong Thom

9,666 3,321 12,987 6,577 2,149 20,159 2,683 3,192 34,761 CHC 4 Siem Reap 7,272 16,969 24,242 12,067 331 3,942 257 25 16,622 STSA 5 Angkor Chum 12,112 41,334 53,446 39,188 14,119 6,459 2,133 18 61,917

6 Phnom Penh 21,469 351 21,820 10,676 3,224 37,056 30 50,985 7 Ang Roka 6,332 3 6,335 4,698 950 - - - 5,648 8 Daun Keo 2,162 2 2,164 4,612 403 - - - 5,015 9 Bati 2,353 1 2,354 1,551 31 - - - 1,582

10 Prey Kabass 2,186 0 2,187 1,596 218 - - - 1,814 BFH 11 Kirivong 4,835 3 4,838 4,798 295 - - - 5,093

12 Ta Khmoa - - 13 Kampot - - - 397 425 14,279 1,816 - 16,917

RACHA/HN 14 Pearaing 2,510 4,978 7,488 3,708 1,057 4,765 15 Bakan 4,216 - 4,216 7,701 1,266 - - - 8,967 16 Sampov Meas 8,256 32,697 40,953 18,513 4,613 1,267 750 - 25,143 17 Battambang 475 700 1,175 1,271 261 79 391 2,002 18 Sangke 572 700 1,272 1,047 128 79 297 1,551 19 Thma Kol 1,670 700 2,370 726 231 79 132 - 1,168

182,317 474,489 656,806 284,252 65,758 213,804 49,031 9,869 622,715

SKY

No.

CHO

SKY

PCHSFA

Income (USD) Expenditures (USD)

Scheme

CAAFW

OD

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6. Progress towards Health Financing Strategies included in the HSP2 HF Strategies in the HSP2

Objectives in the Strategic framework for health financing

Progress reported till end of 2011

Areas for consideration

Increase public spending & improving its efficiency

SO 1: Increase government budget and improve efficiency of government resource allocation for health.

• Public spending above 7% of total Government expenditure

• Budget fully disbursed

• Bottom-up AOP process well established

• Move forward MEF PFM reforms, including:

• Revision of programmatic classification

• Integrating AOP process into Budget Strategic Plan and revised MEF budget classification

• More (flexible) resources at service delivery level needed

Align donors to MoH strategies & plans

SO 2: Align donor funding with MOH strategies, plans and priorities and strengthen coordination of donor funding for health

• Increasing DPs resources are ‘on-planning’ through AOP

• Partners pledge (& fulfill) their resources every year

• Donors to align resources with RGC budget classification to bring on-budget and increasingly use government financial management systems

• Need to reduce multiple management & reporting channels

• HF issues overseeing body might be needed

Develop social health protection mechanisms to reduce financial barriers

SO 3: Remove financial barriers at the point of care and develop social health protection mechanisms

• Expansion of HEF, covering 76% of targeted poor (goal was 80% by 2010); 24% HC

• Wide implementation of poverty targeting tools

• Establishment of insurance for

• OOP high but most still use unregulated private sector

• CBHI expansion requires further study

HEF further development: • Cover all country • Standardized benefit

package • Enhance provider payment

mechanism

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workers, including design with SHI like packages

• Develop institutional arrangement

Move towards managing resources near service delivery level

SO 4: Efficient use of all health resources at service delivery level

• Government resources devoted to MCH

• Midwifery incentives

• Move towards a more active role of PHDs in programmed resources

• Bringing more resources under program based budgeting

• Institutionalize financial monitoring tools including consideration of NHA

• Double burden of diseases: NCDs seem to be underfunded

Use evidence & information to inform health financing policy-making

SO 5: Improve production and use of evidence and information in health financing policy development

• Systematic reporting on health financing reforms

• DPHI playing a

leading role in HF related research

• Further need for nationally led research agenda, coordination of research and planning

Source: HSP2 Mid-Term Review 2011

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7. GLOSSARY User fees Refers to decentralized and affordable user chargesat public health

facilities, as stipulated in Cambodia Health Financing Charter 1996. The Charter certifies the imposition of official fees according to an agreed schedule at affordable rates following consultation with the community. Public hospitals and Health Centers are allowedto implementthis scheme after approval of the MoH.

Exemption A system that allows poor people to receive health care services free of charge at public health facilities. In practice, the exemption system does not work effectively and cannot achieve its desired results, becauseless than half areconsidered too poor to pay for services.

Health Equity Fund A social-transfer mechanism designed to remove financial access to public health facilities by the poor by paying fees for services viaa third-party payer, mainly local NGOs. Pre-identification and post-identification are commonly used to identify the poor, who are entitled to get health services free of charge at the point of use.The third party then reimbursesdirectly the cost of such services usedat facilities on a monthly basis.

Health Equity Fund Implementer (HEFI)An agency whichmanages health equity fund Operator(s).

Health Equity Fund Operator (HEFO)An agency (NGO or any other type of Civil SocietyOrganization) responsible for implementing HEFs,with oversight HEFOs,and representing the voice of and acting in the interest of the poor in coverage areas of HEFs schemes bypurchasing health services from public health providers.

Subsidy (SUB) Subsidy Government fundedscheme(s)wherebypublic health facilities provide services free of charge to the poor patients and their caretakers, but receives by financialcompensationfrom the national budget. The schemes are managed directly by ODs and Hospitals.

Subsidy operator(SUBO)is Any Public Health Authority that is authorized by the Government to receive and manageSUB scheme(s).

Social health protectionis an umbrella term used to describe all schemes and procedures that provide an element of protection against health care disbursements for the poor and for other users. This includes fee exemptions, health equity funding,community based health insurance and social health insurance.

Social health insurance: refers to various compulsory pre-payment schemes within the formal employment sector supported by legislation and usually funded either by the government (for civil servants) or by employers (for formal private-sector employees), often with part-contributions also from the employees.

Voluntary Health Insurance Scheme: refers to private, non-profit, voluntary pre-payment schemes targeted on the informal employment sector of small scale and self-employed urban and rural workers. Such schemes are usually sponsored by an NGO and operated at community level. These schemes are funded by voluntary premium payments by beneficiaries and commonly require subsidies from other donors. Services are provided by contracted health providers usually in the public sector but may also include qualified private providers.

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8. REFERENCES

1. Draft health financing policy, MoH, 2012 2. Health Sector Strategic Plan, MoH -HSP2 2008-2015 3. Strategic Framework for Health Financing, MoH, 2008-2015 4. Joint Annual performance review and health congress report, MoH 5. Bureau of Health Economics and Financing, DPHI, MoH, Annual health financing

Report 2007, 2008, 2009, 2010, 2011 and 2012. 6. General Population Census of Cambodia, 2008, NIS 7. CDHS 2010, NIS, MoP 8. CDC website http://cdc.khmer.biz/index.asp 9. Ministry of Planning, Summary of National Strategy Development Plan (NSDP) 2009-

2013 10. TOFE 2010, Ministry of Economy and Finance. 11. Medium Term Expenditure Framework, MoEF, 20012-2014 12. International monetary fund, Cambodian country report N. 12/46, February 2012 13. OOP analysis using Socio Economics Survey data 2004, 2007, 2009 14. National account 2011, NIS, MoP 15. National Social Security Fund, Annual Report 2010, 2011 16. Evaluation report on SOBO 2011 17. HSP2 Midterm review report 2011 18. Merit base performance incentive (MBPI), OPM, 2008 19. Summary of OASIS, WHO, 2008 20. Annual report of the Department of Financial Industry, MoEF, 2009. 21. Social Protection Expenditure and Performance Review, ILO,2012

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